PRACTICE GUIDELINE Directives Table of Contents What Is a Directive? 3 When Is an Order Required? 3 What Information Does a Directive Need to Include? 3 Who Should Be Involved in Developing a Directive? 4 What Policies Are Needed Before Directives Are 4 Developed and Used? What Are the Responsibilities of the NP or Physician Who Writes the Directive and the Health Professional Who Implements It? 5
VISION Leading in regulatory excellence MISSION Regulating nursing in the public interest Directives Pub. No. 41019 ISBN 978-1-77116-102-2 Copyright College of Nurses of Ontario, 2018. Commercial or for-profit redistribution of this document in part or in whole is prohibited except with the written consent of CNO. This document may be reproduced in part or in whole for personal or educational use without permission, provided that: Due diligence is exercised in ensuring the accuracy of the materials reproduced; CNO is identified as the source; and The reproduction is not represented as an official version of the materials reproduced, nor as having been made in affiliation with, or with the endorsement of, CNO. First Published July 1995 as When, Why and How to Use Medical Directives Revised and Reprinted January 2000 (ISBN 0-921127-87-1) Reprinted October 2000, June 2003, Revised for Web June 2003, Reprinted January 2004 as Medical Directives, Reprinted December 2005. Updated May 2008 as Directives. Updated June 2009 (ISBN 1-897308-54-X). Updated November 2011 for Bill 179 changes. Updated 2014 for Dispensing (ISBN 978-1-77116-019-3). Revised January 2018 for Controlled Act of Psychotherapy. Additional copies of this booklet may be obtained by contacting CNO s Customer Service Centre at 416 928-0900 or toll-free in Canada at 1 800 387-5526. College of Nurses of Ontario 101 Davenport Rd. Toronto, ON M5R 3P1 www.cno.org Ce fascicule existe en français sous le titre : Les directives, n 51019
PRACTICE GUIDELINE 3 What Is a Directive? An order is a prescription for a procedure, treatment, drug or intervention. It can apply to an individual client by means of a direct order or to more than one individual by means of a directive. For the purpose of this document, a directive refers to an order from a physician or Nurse Practitioner (NP). A direct order is client specific. It is an order for a procedure, treatment, drug or intervention for an individual client. It is written by an individual practitioner (for example, physician, midwife, dentist, chiropodist, NP, or Registered Nurse [RN] initiating a controlled act) for a specific intervention to be administered at a specific time(s). A direct order may be written or oral (for example, by telephone). A directive may be implemented for a number of clients when specific conditions are met and when specific circumstances exist. A directive is always written. For the purpose of this document, a directive refers to an order from an NP or physician. The use of the term standing order is not supported by the College of Nurses of Ontario. In the past, a standing order was implemented for every client, regardless of the circumstances. The practitioner implementing the standing order was not expected to exercise any judgment regarding the appropriateness of the order for the client. It is now recognized that knowledge, skill and judgment are critical, and that no order, regardless of how routine it may seem, should be automatically implemented. Standing orders should not be confused with preprinted medical orders that are signed by the physician prior to implementation. When Is an Order Required? An order is required in any of the following instances: when a procedure falls within one of the controlled acts authorized to nursing, in the absence of initiation.1 For example: administering a substance by injection or inhalation, performing a procedure below the dermis, or putting an instrument, hand or finger beyond a body orifice or beyond an artificial opening into the body, dispensing a drug; when a procedure does not fall within any controlled act, but is part of a medical plan of care; when a procedure falls within one of the controlled acts not authorized to nursing; when a procedure/treatment/intervention is not included within the Regulated Health Professions Act, 1991, but is included in another piece of legislation. For example: X-rays under the Healing Arts Radiation Protection Act, or ordering laboratory tests. treating, by means of psychotherapy technique, delivered through a therapeutic relationship, an individual s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual s judgement, insight, behaviour, communication or social functioning. What Information Does a Directive Need to Include? There are a number of specific components required in a directive. They are: the name and description of the procedure(s)/ treatment(s)/intervention(s) being ordered; specific client clinical conditions and situational circumstances that must be met before the procedure(s) can be implemented; clear identification of the contraindications for implementing the directive; the name and signature of the NP or physician approving, and taking responsibility for, the directive; and the date and signature of the administrative authority approving the directive; for example, the Intensive Care Unit Advisory Committee. The degree to which client conditions and situational circumstances are specified will depend on the client population, the nature of the orders 1 For more information about initiation, refer to the College s Authorizing Mechanisms practice document at www.cno.org/docs..
4 PRACTICE GUIDELINE involved and the expertise of the health care professionals implementing the directive. Who Should Be Involved in Developing a Directive? A directive is an order for one procedure or a series of procedures. Although it is by definition a medical document, the collaborative involvement of health care professionals affected directly or indirectly by the directive is strongly encouraged. The health care team needs to determine whether a procedure can safely be ordered by means of a directive, or whether direct assessment of the client by the NP or physician is required before a procedure is implemented. Procedures that require direct assessment of the client by the NP or physician require direct orders. What Policies Are Needed Before Directives Are Developed and Used? Before a directive is adopted as a method for providing health care, there are a number of policies that need to be in place. It is the facility s governing board, in consultation with the medical authority and relevant senior administration, that develops these policies and ensures they are appropriately implemented. These policies include: identification of the types of procedure(s) that may be ordered by means of a directive. It must be clear which types of procedure(s) require a direct order, and which may be implemented when a health care professional has verified that client conditions and circumstances are met; determination of the involvement of the NP/ physician responsible for the care of the client, such as when a directive may be implemented prior to the NP/physician seeing the client; identification of who may implement a directive, including any specific educational requirements, designations or competencies (for example, only RNs in a certain department who have completed a continuing education course, only RNs who have completed an in-service program, all RNs, or all RNs and Registered Practical Nurses [RPNs], etc.); identification of the NPs or physicians to whom a directive applies. It needs to be clearly identified whether a directive is meant to apply to the clients of all NPs or physicians or only clients of selected NPs or physicians; development of a feedback mechanism, including a defined communications path. This enables the health care professional implementing a directive to identify the NP or physician responsible for the care of the client, and to query the order(s) contained within the directive if clarification is required; clearly stated documentation requirements on the part of the health care professional implementing a directive; and identification of tracking/monitoring methods to identify when directives are being implemented inappropriately or are resulting in unanticipated outcomes. It is strongly recommended that the above policies are in place and understood before directives are used to deliver health care within a facility. What Are the Responsibilities of the NP or Physician Who Writes the Directive and the Health Professional Who Implements It? The NP or physician who writes an order for an intervention (whether that order is a direct clientspecific order or is applicable to a number of clients by means of a directive) is responsible for: knowing the risks of performing the intervention being ordered; knowing the predictability of the outcomes associated with the intervention; knowing the degree to which safe management of the possible outcomes requires NP or physician involvement or intervention; ensuring that appropriate medical resources are available to intervene as required; and ensuring that informed consent has been obtained. The health care professional who implements an intervention on the basis of a directive is responsible for: clarifying that informed consent has been obtained; assessing the client to determine whether the
PRACTICE GUIDELINE 5 specific client conditions and any situational circumstances identified in the directive have been met; knowing the risks to the client of implementing the directive; possessing the knowledge, skill and judgment required to implement the directive safely; knowing the predictability of the outcomes of the intervention; determining whether management of the possible outcomes is within the scope of her/his practice; if so, whether she/he is competent to provide such management and if not, whether the appropriate resources are available to assist as required;2 and knowing how to contact the NP or physician responsible for care of the client if orders require clarification. Directives, correctly used, can be an excellent means to provide timely, effective and efficient client care, using the expertise of the NP/physician who orders the directive, and the health care practitioner who uses discretion and judgment when implementing it. It is important to remember that a directive, regardless of how generic its contents, is an order for which the NP/physician has ultimate responsibility. 2 Refer to the College s Decisions About Procedures and Authority practice document at www.cno.org/docs.
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